Symposium ‘Optimaliseren van juist medicijngebruik door ouderen in de eerstelijnsgezondheidszorg´ Promotie Dr Henk-Frans Kwint 29 mei 2013
HMRs In Australia: It can be a family affair
Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA (Acting) Head of Pharmacy May 29th 2013
CRICOS #00212K
HMR in Australia Overview • • • • • • •
Duration of service delivery Process and Payments Statistics and Hurdles Recent Developments in Australia Medication Review Training @UC Cases from a Dutch HMR accredited pharmacist Odds and Ends (if time)
Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA
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Symposium ‘Optimaliseren van juist medicijngebruik door ouderen in de eerstelijnsgezondheidszorg´ Promotie Dr Henk-Frans Kwint 29 mei 2013
HMR in Australia Overview
• • • •
Australian Population Pharmacies Pharmacists Accredited Pharmacists
HMR in Australia Process and Payment 1 2 3 4 6 7 8
• Identify the patient for HMR (any member of the healthcare team, patient or carer) • GP initiates and refers to community pharmacy OR Pharmacist (2012) • Pharmacist conducts patient interview (accredited or community pharmacist) • Pharmacist prepares Medication Management Review (accredited pharmacist) • Pharmacist sends report to GP ($200.00) • GP consultative management plan for patient • GP sends management plan to pharmacy/pharmacist ($150.00)
Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA
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Symposium ‘Optimaliseren van juist medicijngebruik door ouderen in de eerstelijnsgezondheidszorg´ Promotie Dr Henk-Frans Kwint 29 mei 2013
HMR in Australia HMR Statistics (2001-2013) ~150,000
HMR in Australia
Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA
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Symposium ‘Optimaliseren van juist medicijngebruik door ouderen in de eerstelijnsgezondheidszorg´ Promotie Dr Henk-Frans Kwint 29 mei 2013
HMR in Australia HMR Statistics (2001-2010)
HMR in Australia Other Paid Programmes • MedsCheck (MUR) • n~13000 Oct-Dec 2012 • Diabetes Check • n~3000 Oct-Dec 2012 • Clinical Interventions • RMMR • QUM
Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA
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Symposium ‘Optimaliseren van juist medicijngebruik door ouderen in de eerstelijnsgezondheidszorg´ Promotie Dr Henk-Frans Kwint 29 mei 2013
HMR in Australia UC Training for Medication Review
HMR in Australia UC Training for Medication Review •
MedicineSmart@UC • 2 contracts
Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA
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Symposium ‘Optimaliseren van juist medicijngebruik door ouderen in de eerstelijnsgezondheidszorg´ Promotie Dr Henk-Frans Kwint 29 mei 2013
HMR in Australia UC Training for Medication Review • Hospitalised for heart failure in 2011 – verapamil, monopril, hydrochlorothiazide – frusemide • Sitaglitpin, gliclazide, Insulin glargine (Lantus) – BSLs 10-14 (HbA1c 11.2%)
• Outcomes.
HMR in Australia UC Training for Medication Review •
Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA
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Symposium ‘Optimaliseren van juist medicijngebruik door ouderen in de eerstelijnsgezondheidszorg´ Promotie Dr Henk-Frans Kwint 29 mei 2013
HMR in Australia UC Training for Medication Review
HMR in Australia Meet Katja
• • • •
MPharm (RuG) Veendam Aust: 2006 HMR 2009 – ~1000
• Locum PhC
Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA
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Symposium ‘Optimaliseren van juist medicijngebruik door ouderen in de eerstelijnsgezondheidszorg´ Promotie Dr Henk-Frans Kwint 29 mei 2013
HMR in Australia Referral
HMR in Australia Case 1 • 77 yrs – Urgent HMR – Nausea, weight loss (suspect ADR) – 7/2/13 • • • • • • • • • • • •
Dementia Severe depression OSA Valvular Heart Disease Mild aortic stenosis ↑Chol Hypertension Meniere’s disease OA T2DM (Feb 2012) Tiredness (Dec 2012) Orthostatic hypotension (21/1/13)
Prescribed Drug and Dose Gliclazide MR 60mg: 1 tablet daily Domperidone 10mg: 1 tablet tds prn Fentanyl 100 Patch: 1 every 3 days Reboxetine 4mg: 1 ½ tablet daily Ferrous fumarate/folic acid 310mg/350mcg: 1 tablet daily Sitagliptin/Metformin 50/1000mg: 1 tablet twice daily [ Atorvastatin 10mg: 1 tablet daily [Lipitor®] Prazosin 1mg: ½ a tablet twice a day Mirtazapine 45mg: 1 tablet at night Paracetamol 500mg: 2 tablets qds prn Moxonidine 400mcg: 1 tablet daily Betahistine 16mg: 1 tablet twice daily Ramipril 2.5mg: 1 capsule daily
Frequency according to patient 1 tablet daily (packed in Medico pack) 1 tablet three times a day
Purpose according to pt “?” “Dizziness, nausea” “Pain”
1 patch every 4 days
“Depression”
1 ½ tablets daily (packed in Medico pack) 1 tablet daily (packed in Medico pack) 1 tablet twice daily (packed in Medico pack) 1 tablet daily (packed in Medico pack) ½ a tablet twice daily (packed in Medico pack) 1 tablet daily (packed in Medico pack) Not using
“?” “?” “?” “?” “Depression”
Stopped by cardiologist 1 tablet twice daily (packed in Medico pack) 1 tablet daily (packed in Medico pack)
“?”
Prescribed Drug and Dose
Frequency according to patient
Purpose according to pt
Diltiazem 60mg
2 tablets in the morning and 1 tablet at night 1 tablet daily
“Palpitations”
Glucosamine 750mg
“?”
“Arthritis”
Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA
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Symposium ‘Optimaliseren van juist medicijngebruik door ouderen in de eerstelijnsgezondheidszorg´ Promotie Dr Henk-Frans Kwint 29 mei 2013
HMR in Australia Case 1
HMR in Australia Case 1
Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA
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Symposium ‘Optimaliseren van juist medicijngebruik door ouderen in de eerstelijnsgezondheidszorg´ Promotie Dr Henk-Frans Kwint 29 mei 2013
HMR in Australia Case 1
NB: no anticoagulant, Fe supps, no pain, Betahistine ineffective,
HMR in Australia Case 2 • 76 yrs – > 5 meds – Pt. request – 27/2/13 – Patient concerns • Nausea, constipation • Sertraline not effective • Suspected UTI? – Hexamine recently ceased – Abx not working.
Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA
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Symposium ‘Optimaliseren van juist medicijngebruik door ouderen in de eerstelijnsgezondheidszorg´ Promotie Dr Henk-Frans Kwint 29 mei 2013
HMR in Australia Case 2 • • • • • • • • • • • •
Hypertension Mild COPD/Asthma Diverticular disease Spondylosis # ® NOF (OP) CKD (stage 3) Recurrent UTI Dyslipidaemia Insomnia Dry eyes Bilateral cataracts ……………………etc.
Prescribed Drug and Dose Aspirin 100mg: 1 tablet daily Candesartan/Hydrochlorothiazide 16/12.5mg: 1 tablet daily Calcium 600mg & vitamin D 400IU: 1 tablet bd Fish oil 1000mg Glucosamine 1000mg
Cephalexin 500mg Lacri-Lube lubricating eye ointment (paraffin liquid, paraffin soft): prn Nitrazepam 5mg: ½ a tablet at night prn Paracetamol SR 665mg: 2 tablets tds Reboxetine 4mg: 1 tablet daily [Edronax®] Prochlorperazine 5mg Budesonide/Eformoterol 100/6mcg/dose Turbuhaler: 2 doses once daily Salbutamol 100mcg/dose Sertraline 100mg: 1 tablet daily
Frequency according to patient 1 tablet daily ½ a tablet daily 1 tablet twice daily
Purpose according to pt “Prevent stroke” “Blood Pressure” “Supplement”
1 capsule daily Is using 1 tablet that contains glucosamine 1500mg and chondroitin 1200mg daily 1 tablet twice daily Applies at night
“UTI” “Dry/sore eyes” “Sleep”
½ tablet when required (approx 2 times a week) 2 tablets three times daily 1 tablet daily Occasional use (approx 2 tablets per month) 1 dose twice daily
Not often except in last week when feeling unwell 1 tablet daily
Prolia 60mg/ml (Denosumab) Coloxyl with Senna Loperamide 2mg Rennie (antacid)
Every 6 months 2 tablets daily Rarely using Approx Once a week
“Pain” “anxiety/depre ssion “Nausea” “Asthma”
anxiety/depres sion”
“?” “Constipation” “Diarrhoea” “Reflux”
HMR in Australia Case 2
• Hypercalcaemia – Calcium/vit D + hydrochlorothiazide •
Stones Bones Groans Thrones Psychiatric overtones
• Recent aspirin use (no PPI & and SSRI) • Two antidepressants (anxiety since 1965) • No oestrogen cream used
Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA
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Symposium ‘Optimaliseren van juist medicijngebruik door ouderen in de eerstelijnsgezondheidszorg´ Promotie Dr Henk-Frans Kwint 29 mei 2013
HMR in Australia Case 2
“I need one of these” Son of case 2
HMR in Australia Case 3 • 41 yrs – – – – – – – – – – –
Alcohol abuse Back pain Knee pain Neck pain Testicular cancer Concussion Chronic migraine PTSD Night terrors Mild dyslipidaemia Libido reduction
Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA
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Symposium ‘Optimaliseren van juist medicijngebruik door ouderen in de eerstelijnsgezondheidszorg´ Promotie Dr Henk-Frans Kwint 29 mei 2013
HMR in Australia Case 3 • Patient concerns – – – – –
Nausea Pain Nightmares Zolpidem wants to stop Libido reduction
Prescribed Drug and Dose Acamprostate 333mg: 3 tablets bd
Frequency according to patient 3 tablets twice daily
Duloxetine 60mg: 2 tablets daily [Cymbalta®] Sodium valproate EC 500mg: 1 tablet bd Prazosin 1mg: 3 tablet at night [Minipress®] Naltrexone 50mg: 1 tablet daily
2 tablets daily
Ibuprofen/codeine 200/12.8mg
Approx 2 tablets three times a day Approx 2-4 tablets per week Occasional use 1 tablet prn 1 tablet at night
Paracetamol 500mg Cyproheptadine 4mg Quetiapine 25mg: 1 tablet daily prn Quetiapine XR 150mg: 1 tablet daily Prochlorperazine 5mg: 1 tablets three times daily prn Zolpidem 10mg: 1 tablet nocte prn Vitamin B1 (Thiamine) 100mg: 1 tablet bd Diazepam 5mg: 1 prn
1 tablet twice daily
Purpose according to pt “Alcohol dependence” “Depression/An xiety” “Migraines”
3 tablets at night
“Nightmares”
1 tablet daily
“Alcohol dependence” “Pain”
Approx 2-3 times a week 1 tablet daily 1 tablet daily
“Pain” “Sleep” “Anxiety” “Depression/An xiety” “Nausea” “Sleep” “Supplement”
Approx 2 tablets per week
“Severe pain”
Oxycodone 5mg [Endone] Krill oil The good vitamin (contains: 50mg vitamin C, 50mg vitamin B6, 301.5mg Magnesium, 4mg Manganese and 2.5 mcg vitamin D)
“Anxiety”
1 capsule daily 1 tablet daily
“Cramps”
HMR in Australia
Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA
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Symposium ‘Optimaliseren van juist medicijngebruik door ouderen in de eerstelijnsgezondheidszorg´ Promotie Dr Henk-Frans Kwint 29 mei 2013
HMR in Australia Case 4 • Patient concerns – Increasingly difficulty with breathing – last 6 months “it’s different”
• • • • • • •
COPD CVA Depression AF Hypertension Dyslipidaemia GORD
Hydrocortisone 1% cream: apply bd Omeprazole 20mg: 1 tablet daily [Losec®] Paracetamol/codeine 500mg/30mg: 2 tablets bd [Panadeine Forte®] Hydroxychloroquine 200mg: 1 tablet daily [Plaquenil®]
Applies 1-2 times a day 1 tablet daily
Dabigatran 150mg: 1 tablet bd [Pradaxa®] Sertraline 100mg: 2 tablets daily [Xydep®] Sotalol 80mg: ½ tablet twice daily [Sotacor®]
1 tablet twice daily
Tiotropium 18mcg: 1 capsule daily [Spiriva®]
1 capsule daily
Oxycodone/Naloxone SR 40/20mg: 1 tablet twice daily [OxyContin®] Vitamin B1 (Thiamine) 100mg: 1 tablet daily [Betamin®]
1 tablet twice daily
“Itch” “Reflux” “Pain”
Approx 4-6 tablets daily 1 tablet at night
2 tablets each morning ½ a tablet twice daily
1 tablet daily
“arthritis” “Blood Thinner” “Depression” “Heart” “Lungs” “Pain” “Alcohol use” “?”
Ramipril 10mg: 1 capsule daily 1 capsule daily [Tritace/Tryzan®] Ezetimibe/simvastatin 10/10mg: 1 tablet daily [Vytorin®] Salbutamol MDI 100 mcg/dose Mometasone 1mg/g lotion Swisse ultiboost immune (Olive leaf, Zn, Mg, Co, vit c and biflavonid extract). Diazepam 2mg
Loperamide 2mg [Diareze] Donnatab (contains hyoscyamine sulf 103.7mcg, atropine sulf 19.4mcg and hyoscine 6.5mcg)
“?”
1 tablet at night When required
“Asthma”
When required 1 tablet daily
“Itchy scalp”
When required (approx 3 tablets per month) Rarely using Approx 4 tablets per months
“Panic/anxiet y” “Diarrhoea” “Cramps”
HMR in Australia Overview
Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA
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Symposium ‘Optimaliseren van juist medicijngebruik door ouderen in de eerstelijnsgezondheidszorg´ Promotie Dr Henk-Frans Kwint 29 mei 2013
HMR in Australia Drs and Recommendations • Psychological Reactance
HMR in Australia Valmer Study
Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA
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Symposium ‘Optimaliseren van juist medicijngebruik door ouderen in de eerstelijnsgezondheidszorg´ Promotie Dr Henk-Frans Kwint 29 mei 2013
Guidelines
Gout
Diabetes
OP
IHD
HPT
GORD Presentation
Presentation
Presentation Presentation
Presentation
Diagnosis
Diagnosis
Diagnosis Diagnosis
Patient
Diagnosis Heart Diagnosis
Evaluation
Real Life Evaluation
failure
Evaluation
obese
Evaluation
Wife has Evaluation affair
Management Management
Presentation
Management Alcoholism
Impotent Renal impairment
Management
Renal failure
Son Evaluation Suicide s
Management Management
HMR in Australia Drs and Recommendations • Hospital-acquired infections – 1 in 11 (13% mortality) – Up to 30% are considered preventable through hand washing – Hand washing by doctors known to be poor (<50%)
Grol and Grimshaw Lancet 2003; Girou BMJ 325 17 2002)
Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA
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Symposium ‘Optimaliseren van juist medicijngebruik door ouderen in de eerstelijnsgezondheidszorg´ Promotie Dr Henk-Frans Kwint 29 mei 2013
HMR in Australia Medication Review Recommendations •
Klopfer Hosp Pharm 1990
•
Leape JAMA 1999
•
Gilbert 2002 MJA
•
Dename J Am Pharm Assoc 2009
•
Wang HY Transplant Proc 2008
•
McCollum 2009 Am J Pharm Ed
•
Davis Am J Geriatr Pharmacother 2007
•
Michaels J Am Pharm Assoc 2010
•
Naunton 2003 JPPR
– 85% (review of 23 studies) – 99% (ICU) – 42% (collaborative medication reviews) – 61% (diabetics) – 96% (renal unit) – 32% (students) – 69% (Veterans) – 42-60% acceptance; 62-86% implemented – 79% (post-discharge medication reviews)
HMR Objectives • Achieve safe, effective, and appropriate use of medicines by detecting and addressing medicine-related problems that interfere with desired patient outcomes • Improve the patient's quality of life and health outcomes using a best practice approach • Improve the patient's, and health professional’s knowledge and understanding about medicines • Facilitate cooperative working relationships between members of the health care team in the interests of patient health and wellbeing
Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA
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Symposium ‘Optimaliseren van juist medicijngebruik door ouderen in de eerstelijnsgezondheidszorg´ Promotie Dr Henk-Frans Kwint 29 mei 2013
HMR Objectives (in short...) • Achieve QUM by fixing medicine-related problems • Improve quality of life and health outcomes through best practice • Improve everyone’s knowledge and understanding about medicines • Get the health care team working together to benefit patients
Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA
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Symposium ‘Optimaliseren van juist medicijngebruik door ouderen in de eerstelijnsgezondheidszorg´ Promotie Dr Henk-Frans Kwint 29 mei 2013
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Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA
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Symposium ‘Optimaliseren van juist medicijngebruik door ouderen in de eerstelijnsgezondheidszorg´ Promotie Dr Henk-Frans Kwint 29 mei 2013
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HMR in Australia Other Paid Programmes
Presentatie van Mark Naunton BPharm (Hons), MPS, MSHPA, PhD, AACPA
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